INTRODUCTION — The clinical spectrum of urothelial bladder cancer ranges from non-muscle-invasive to metastatic disease at presentation. The most important treatment-related issues include the identification of those who can be adequately managed without total cystectomy, those who need radical cystectomy, and those who require a combined modality approach that may include chemotherapy and/or radiation therapy.
Radical cystectomy is the treatment of choice for nonmetastatic muscle-invasive bladder cancer and remains the standard by which other treatments are judged. It also has a role in carefully selected patients with non-muscle-invasive disease as well as in patients with locally advanced or metastatic bladder cancer who achieve a major clinical response to cisplatin-based chemotherapy.
The indications, techniques, and outcomes of radical cystectomy are reviewed here. Other treatments of bladder cancer are discussed in these other topics:
Muscle-invasive bladder cancer — The general approach to initial therapy for muscle-invasive bladder cancer is presented in this algorithm (algorithm 1) and discussed in detail elsewhere. (See "Overview of the initial approach and management of urothelial bladder cancer", section on 'Muscle invasive disease'.)
●Radical cystectomy is indicated for patients with T2 to T4a, M0, muscle-invasive bladder cancer who are surgical candidates and are willing to accept urinary diversion. Eligible patients typically receive cisplatin-based neoadjuvant chemotherapy, but not radiation therapy, prior to cystectomy. (See "Neoadjuvant treatment options for muscle-invasive urothelial bladder cancer", section on 'Radical cystectomy'.)
●Salvage radical cystectomy may be indicated for initially inoperable patients (clinical stage T4b and/or bulky clinical stage N1 to 3) who are rendered resectable following a favorable response to chemotherapy.
Non-muscle-invasive bladder cancer
●Although the standard approach for high-grade non-muscle-invasive bladder cancer (Ta, T1, carcinoma in situ [Tis] (table 1)) is transurethral resection followed by intravesical immunotherapy with Bacillus Calmette-Guérin (BCG), radical cystectomy may be indicated for patients who either have very high-risk features or persistent/recurrent disease despite less invasive therapy. (See "Overview of the initial approach and management of urothelial bladder cancer", section on 'Indications for cystectomy'.)
●Other less common indications for radical cystectomy in patients without muscle-invasive bladder cancer include:
•Diffuse, Ta low-grade bladder cancer that is not amenable to complete transurethral resection. (See "Pathology of bladder neoplasms", section on 'Papillary lesions'.)
•Bladder cancers that cause symptoms (eg, hemorrhage, urinary frequency) that cannot be managed endoscopically or medically.
SURGICAL STEPS — Radical cystectomy entails removal of the bladder along with the organs at highest risk of harboring tumors that extend beyond the bladder and regional pelvic lymph nodes .
Cystectomy — Surgery can be performed with an open or minimally invasive transperitoneal approach by surgeons experienced with these techniques (figure 1). The ureters are identified at the pelvic brim and mobilized down to and divided just above the ureterovesical junction. A terminal ureteral biopsy may be sent for frozen section analysis to rule out carcinoma in situ. The bladder is then progressively freed from surrounding structures, beginning posteriorly, proceeding laterally, and then anteriorly, including transection of the urethra. A urethrectomy should be performed for men who have invasive cancer at the apical urethral margin of resection  and in women not undergoing reconstruction with a neobladder in order to reduce the likelihood of a positive surgical margin or tumor recurrence. (See 'Urethral recurrence after radical cystectomy' below.)
The need to resect organs adjacent to the bladder differs between sexes. Because sexual dysfunction is a known complication of pelvic surgery, sexual-preserving techniques of radical cystectomy have been developed for both males and females. Such techniques should be offered to those who are motivated to preserve sexual function as the majority of patients will benefit .
Men — In men, standard radical cystectomy generally includes removal of the prostate, seminal vesicles, distal ureters, and regional lymph nodes. This frequently results in damage to the neurovascular bundles, thus causing impotence. Men with good erectile function who desire to preserve their potency after radical cystectomy may be candidates for preservation of the cavernous nerves similar to that performed during nerve-sparing radical prostatectomy. (See "Radical prostatectomy for localized prostate cancer", section on 'Nerve-sparing approach'.)
Four neurovascular bundle-sparing techniques have been described for men:
●Prostate and seminal vesicle sparing
●Prostate capsule sparing
●Seminal vesicle sparing
In a 2017 systematic review, these four techniques were associated with superior postoperative potency rate but comparable local and distant recurrence and overall and disease-free survival rates compared with standard radical cystectomy at intermediate (three to five years) follow-up . There was no superiority of any one technique [5,6]. Thus, the choice of techniques can be by surgeon preference.
However, nerve-sparing cystectomy requires dissection close to the urinary bladder, exposing patients to the risks of positive soft tissue surgical margins. Thus, candidates for nerve-sparing cystectomy should be carefully selected based on the following criteria :
●Absence of tumor at the levels of the prostate, prostatic urethra, and bladder neck
Erections sufficient for intercourse are reported in 31 to 50 percent of patients within one to two years after nerve-sparing cystectomy, although most patients require assistance with phosphodiesterase-5 inhibitors, such as sildenafil, vardenafil, or tadalafil [7-9].
Women — In women, standard radical cystectomy, also known as anterior exenteration, includes removal of the bladder, entire urethra and adjacent vagina, uterus, distal ureters, and regional lymph nodes. Given that involvement of the female reproductive organs (ie, uterus, cervix, ovaries, and vagina) is not common , pelvic organ-preserving techniques can be applied in women to preserve the neurovascular bundle, vagina, uterus, and/or ovaries .
A 2017 systematic review of women undergoing radical cystectomy with orthotopic neobladder reconstruction concluded that a pelvic-organ-sparing approach is oncologically sound and functionally superior to the standard technique, albeit based on low-quality retrospective evidence . However, women undergoing such a procedure should have :
●Absence of tumor at the levels of the urethra and bladder neck
In addition, women with a family history of breast or ovarian cancer should undergo bilateral salpingo-oophorectomy. (See "Risk-reducing salpingo-oophorectomy in patients at high risk of epithelial ovarian and fallopian tube cancer".)
Lymphadenectomy — The extent of pelvic lymph node dissection is defined anatomically by primary and secondary nodal drainage of the bladder. With radical cystectomy, all patients should undergo at least a standard bilateral pelvic lymphadenectomy, which includes the external and internal iliac and obturator nodes, with removal of a minimum of 12 lymph nodes . (See 'Prognostic factors for survival' below.)
Some evidence suggests that an extended lymph node dissection may be beneficial at the time of radical cystectomy [13,14]. The extended template includes the presacral and common iliac lymph nodes up to the aortic bifurcation and may include removal of the retroperitoneal lymph node proximal to the aortic bifurcation to the level of the inferior mesenteric artery (superextended lymph node dissection).
However, the Association of Urologic Oncology AB25/02 randomized phase III trial of extended versus standard pelvic lymph node dissection failed to show a significant impact of the former on recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) in 401 patients with cT1-4aN0M0 urothelial carcinoma of the bladder who had not received prior chemotherapy . The impact of this trial on contemporary practice is limited by the exclusion of neoadjuvant chemotherapy and the relatively low use of adjuvant chemotherapy for eligible patients (58 of 205 [28 percent]). A Cochrane review based on this single trial was inconclusive and called for more trials . A similar trial, SWOG S1011, has completed accrual but has not reported the primary endpoint (NCT01224665).
Our preference is to perform an extended lymphadenectomy, at least up to the aortic bifurcation and preferably up to the origin of the inferior mesenteric artery, especially when the cystectomy is for high-grade muscle invasive disease, though the benefit has not been established in phase III trials. High-extended bilateral pelvic and retroperitoneal lymph node dissection can be performed laparoscopically or robotically, typically up to the aortic bifurcation or origin of the inferior mesenteric artery, in a manner similar to that of open cystectomy .
Urinary diversion — Removal of the bladder requires that the urinary flow be redirected, which may result in either a noncontinent or continent diversion. The choice of urinary diversion is based upon patient and surgeon preference and may be influenced by the extent of cancer and other patient-related factors. These options and the issues involved in choosing an approach for an individual patient are discussed separately. (See "Urinary diversion and reconstruction following cystectomy".)
SURGICAL APPROACHES — Radical cystectomy can be performed open or with one of the minimally invasive techniques (laparoscopic or robotic). The goal of minimally invasive radical cystectomy is to reproduce the oncologic results of an open procedure while minimizing surgical complications and postoperative recovery time. The techniques of minimally invasive radical cystectomy continue to evolve. Our preference is to use the robotic technique, although the choice of approach should be based on patient and tumor factors as well as the surgeon's expertise and experience.
Open — Traditionally, radical cystectomy has been performed using an open approach that allows wide excision of the bladder, extended lymph node dissection, and a full range of urinary diversion.
Laparoscopic — Laparoscopy was first used for removal of the urinary bladder in 1992 , and subsequent advances have evolved toward a robotic-assisted intracorporeal approach to include extended lymph node dissection and totally intracorporeal urinary diversion.
Between 1999 and 2006, the authors performed laparoscopic radical cystectomy in 54 patients for bladder cancer . Of these, 17 underwent a totally laparoscopic approach for the cystectomy and urinary diversion, while 37 underwent laparoscopic cystectomy, followed by the urinary diversion procedure (ileal conduit or orthotopic neobladder) through a mini-laparotomy open incision. The lower rate of perioperative complications in the open-assisted group led us to discontinue a totally laparoscopic approach. Major complications associated with a totally laparoscopic approach include bowel leak and/or urine extravasation and sepsis. However, advances in robotic technology and techniques have led to a resurgence of a purely intracorporeal minimally invasive approach to radical cystectomy.
Robot-assisted — Robot-assisted radical cystectomy has evolved from, and further extended, the purely laparoscopic approach and has steadily increased in popularity among urologists who are familiar with robotic techniques. Robotic technology aids complex laparoscopic surgery due to three-dimensional visualization and wristed, articulating instruments, which facilitate intracorporeal suturing. According to National Inpatient Sample (2008–2014) data, robot-assisted radical cystectomy utilization increased from 12.2 percent in 2011 to 22.8 percent in 2014 .
At the author's institution, robot-assisted radical cystectomy comprised 40 percent of all radical cystectomies . Following robot-assisted radical cystectomy and high-extended bilateral lymphadenectomy, we now perform completely intracorporeal urinary diversion (instead of using a mini-laparotomy). Complication rates and oncologic outcomes of robot-assisted radical cystectomy are similar to those cited for open techniques. (See 'Open versus minimally invasive approach' below.)
While the most common urinary diversions performed after robotic radical cystectomy have been an ileal conduit or an ileal orthotopic neobladder, we have added robotic continent cutaneous diversions to our reconstructive armamentarium as well . (See "Urinary diversion and reconstruction following cystectomy".)
Operative morbidity and mortality — Patients with muscle-invasive bladder cancer typically are older and frequently have substantial comorbidities. The median age in large series ranges from 63 to 67 years, with approximately 5 percent over 80 years [23,24]. Furthermore, 34 to 50 percent are classified as high perioperative risk on the basis of an American Society of Anesthesiologists score of 3 or greater (table 2) [25-27].
Improvements in surgical technique and perioperative care have reduced the morbidity and mortality of radical cystectomy, although short-term complications and perioperative mortality are reported in 30 to 70 percent and 0.8 to 3 percent of patients, respectively, in single-institution and population-based studies [28-31]. The frequency of complications and mortality appears to be related to surgeon experience and hospital volume as well as the age and medical comorbidities of the patient .
The most common causes of major complications include cardiovascular diseases, septic complications from urine or bowel leak, wound dehiscence, pulmonary embolus, and hemorrhage . Common late (>90 day) complications include ventral hernia, calculus formation, ureteroenteric stricture, and parastomal hernia in all patients, as well as loss of kidney function and B12 deficiency in those over 70 .
Prognostic factors for survival
●Tumor stage is among the most important factors for predicting both relapse and survival following radical cystectomy. In the absence of neoadjuvant chemotherapy, the outcomes following radical cystectomy correlate with the extent of local invasion and with the presence or absence of lymph node involvement [35-42]:
•Approximately 50 to 60 percent of patients with invasive bladder cancer (clinical stage T2 to T4a) have organ-confined disease without lymph node involvement (pathologic stage pTis to T2, pN0). In this group, long-term survival is reported in 75 to 85 percent of cases.
•In 20 to 30 percent of cases, local extension into the perivesical fat (pT3a to b) and/or adjacent pelvic viscera (pT4a) will be present in the cystectomy specimen without lymph node disease (N0). Long-term survival in this setting is approximately 45 to 55 percent of these patients.
•In 20 to 30 percent of patients, regional lymph node metastasis (pTany, pN1 to 3) is identified, and this is associated with a substantially poorer prognosis, with 25 to 35 percent of patients remaining disease free. However, the survival of node-positive patients also depends on the T stage. As an example, pT2N1 patients have a 50 percent five-year survival probability.
●Neoadjuvant or adjuvant therapy – Neoadjuvant chemotherapy results in a lower risk of recurrence and an improvement in overall survival compared with surgery alone. For patients who receive neoadjuvant chemotherapy, the post-chemotherapy extent of residual local disease is also strongly associated with survival, with those patients achieving a complete pathological response (no residual tumor within the bladder and lymph nodes) having the most favorable prognosis. (See "Neoadjuvant treatment options for muscle-invasive urothelial bladder cancer".)
For patients in whom neoadjuvant chemotherapy was not administered, consideration of adjuvant chemotherapy is reasonable based on risk of recurrence and prognosis. (See "Adjuvant therapy for muscle-invasive urothelial carcinoma of the bladder".)
●Surgical factors – Achieving negative surgical margins and removing sufficient lymph nodes have been associated with improved survival and local recurrence rate after adjustment for pathologic factors and neoadjuvant chemotherapy usage by multivariate analysis . Surgeon experience also impacts patient outcomes.
•Surgical margin – A 2017 meta-analysis of 36 studies associated a positive surgical margin with poorer survival after radical cystectomy for bladder cancer .
•Lymph node count – Removal of >10 lymph nodes was associated with increased overall survival (hazard ratio 0.52, 95% CI 0.43-0.64) . Hospitals that achieve high lymph node counts tend to have higher survival rates after radical cystectomy for bladder cancer .
•Surgeon experience – Surgeon experience and institutional volume strongly predict favorable outcomes for either open or robotic techniques .
•Lymphovascular invasion – Lymphatic or vascular invasion is an independent predictor of progression in T1 and muscle-invasive, node-negative bladder cancer in several cohorts [48-50].
•Extracapsular extension of lymph node metastasis – On multivariate analysis, extracapsular extension of lymph node metastases is a strong prognostic factor .
•Molecular markers – Molecular markers, such as p53, p21, p27kip1, pRB, and p16, are independent predictors of post-cystectomy survival in several series [52-55]. Multiple studies have suggested that panels of such markers may be better at predicting recurrence and/or survival following initial treatment [55-57]. However, these markers are not routinely evaluated in cystectomy specimens and require further validation before they can be adopted for routine use .
Urethral recurrence after radical cystectomy — Second primary urothelial carcinoma in the urethra following radical cystectomy is uncommon (0.8 to 13.7 percent; average 4.6 percent). Male patients treated with non-orthotopic neobladder diversion as well as patients with prostatic involvement and tumor multifocality seem to be at the highest risk of urethral recurrence after radical cystectomy . Incidence is also increased for patients with pathologic locally advanced or node metastatic cancer.
Urethral recurrence following radical cystectomy and orthotopic urinary diversion in women is rare but aggressive. Solitary and noninvasive recurrences have a favorable prognosis; however, invasive disease is associated with dismal prognosis, with a median survival of only six months [60,61]. (See "Urinary diversion and reconstruction following cystectomy", section on 'Recurrent urothelial cancer'.)
Patients with urethral recurrence have a five-year disease-free survival from 47 to 63 percent and an overall survival from 40 to 74 percent . Treatment depends on stage and the presence of distant metastasis and is discussed elsewhere. (See "Treatment of metastatic urothelial cancer of the bladder and urinary tract".)
Open versus minimally invasive approach — Robot-assisted radical cystectomy is most often compared with open radical cystectomy. There is a reasonable amount of data on short-term, perioperative outcomes, but data on long-term oncologic outcomes are more limited.
Perioperative — A number of randomized trials comparing robot-assisted radical cystectomy with open radical cystectomy have been published [62-66]. Two 2019 meta-analyses (one of them a Cochrane review) of 540 participants in five randomized trials showed that robot-assisted cystectomy decreases the risk of perioperative blood transfusion (relative risk [RR] 0.58, 95% CI 0.43-0.80) and marginally decreases length of stay (RR -0.63 days, 95% CI -1.21 to -0.05) but is associated with a longer operative time (mean difference 68.51 minutes, 95% CI 30.55-105.48) compared with open radical cystectomy . Otherwise, the two techniques have similar outcomes with regards to time to recurrence, rates of major complications, quality of life, and positive margin rates .
However, most of the randomized trials comparing robot-assisted radical cystectomy with open radical cystectomy have used an open, rather than intracorporeal, approach to urinary diversion [62-65]. Complications from a radical cystectomy are more often directly, or indirectly, related to urinary diversion, and this was performed open in earlier randomized trials.
●In the first randomized trial comparing open and robot-assisted radical cystectomy with totally intracorporeal urinary diversion , the overall perioperative transfusion rate was lower in patients treated by robotic compared with open surgery (22 versus 41 percent). Other short-term outcomes, such as perioperative complications, hospital stay, and six-month health-related quality of life, were largely comparable between groups. Oncologic and functional outcomes will be assessed at longer follow-up.
●In another randomized trial that included 317 of 338 randomized patients who underwent radical cystectomy, robot-assisted radical cystectomy with intracorporeal urinary diversion resulted in fewer thromboembolic complications (1.9 versus 8.3 percent) and wound complications (5.6 versus 16.0 percent) than open radical cystectomy . Patients undergoing robotic cystectomy reported greater quality of life and less disability at 5 and 12 weeks, but not after 12 weeks. Robotic surgery also resulted in two more median days alive and out of the hospital within 90 days of surgery (82 versus 80), a difference that was statistically significant but of uncertain clinical importance.
A retrospective review from the International Robotic Cystectomy Consortium database evaluated the outcomes of patients undergoing robot-assisted radical cystectomy with an extracorporeal versus intracorporeal diversion . The intracorporeal group demonstrated a significantly lower rate of overall complications, gastrointestinal complications, and 30 and 90 day readmission rates. There were no differences in reoperation rates or operative times . This retrospective review provided an initial insight into the potential benefits of intracorporeal diversion.
Another single-center retrospective study of 948 patients compared the outcomes of open cystectomy and robot-assisted cystectomy with intracorporeal diversion or extracorporeal diversion. The authors found that robotic cystectomy with intracorporeal diversion was associated with less blood loss, shorter hospitalization, lower ileus rate, and lower 30 and 90 day major complication rates .
Due to the cost of the robot, disposables, and annual maintenance contract, direct costs are higher for robot-assisted radical cystectomy ; however, there is some suggestion that lower hospital costs associated with shorter length of stay and fewer complications may compensate [74-76]. A population-based study reported that overall cost differences between robot-assisted radical cystectomy and open radical cystectomy are not different for high-volume surgeons (>7 per year) and high-volume hospitals (>19 per year) . These authors estimated that if the length of stay could be reduced to no more than seven days, which is achievable using enhanced recovery pathways, then robot-assisted radical cystectomy may be cost effective, particularly for high-volume centers .
Oncologic — Survival data are available for oncologic outcomes following laparoscopic/robotic cystectomy [78-82]. There appear to be no significant differences for a laparoscopic/robotic approach compared with the open approach. However, high-quality data are limited.
The larger series with longer follow-ups are retrospective and therefore should be interpreted with caution.
●A retrospective study of the International Robotic Cystectomy Consortium database evaluated the long-term oncologic outcomes of 702 patients who underwent robot-assisted radical cystectomy with a median follow-up of 67 months (interquartile range [IQR] 18 to 84 months). Five-year disease-specific survival, cancer-specific survival, and overall survival (OS) were 67, 75, and 50 percent, respectively . Surgical margins were positive in 8 percent of patients. The median lymph node yield was 16. Non-organ-confined disease and positive surgical margins were associated with poorer survival. These data are limited by a mix of retrospective and prospective data and no open comparison set.
●Another retrospective review from the Mayo Clinic Arizona with a median follow-up of 66 months found similar recurrence-free survival (RFS), OS, and recurrence patterns among 203 patients who underwent robot-assisted radical cystectomy and 278 patients who underwent open surgery. Patients who underwent robot-assisted cystectomy had a 5 and 10 year RFS of 71 and 70 percent and a 5 and 10 year OS of 59 and 40 percent, respectively, which are not statistically different from those who underwent open surgery .
Several randomized trials provided prospective data on survival and cancer recurrence. Unfortunately, most of them are either by design underpowered to detect a small difference in oncologic outcomes or limited in the duration of follow-up.
●A report provided an update on secondary outcomes (oncologic) of an earlier randomized trial that was powered to detect a difference in 90 day complication rate between robot-assisted and open radical cystectomy as the primary outcome . Since this trial was completed in 2013, the authors now have a median follow-up of 4.9 years (IQR 3.9 to 5.9) in 118 patients. The secondary outcomes analyzed were recurrence-free, cancer-specific, and overall survival. No differences were seen in recurrence (p = 0.4), cancer-specific survival (p = 0.4), or OS (p = 0.8). However, the pattern of first recurrence demonstrated a nonstatistically significant increase in distant metastatic events for those undergoing open radical cystectomy and a greater number of local/abdominal sites in the patients who underwent robotic surgery. The major limitation is that the trial was not powered to detect differences in cancer recurrence or survival outcomes .
●Another update on an earlier trial (CORAL) also found similar five-year survival among patients who underwent open, laparoscopic, or robotic radical cystectomy [85,86]. Similarly, however, that trial was also not sufficiently powered to detect survival differences.
●The largest multicenter randomized trial to date (RAZOR trial) was a randomized phase 3 noninferiority trial with a primary endpoint of two-year progression-free survival. A total of 302 patients (150 in the robot-assisted group and 152 in the open group) were analyzed, the majority with organ-confined disease. The two-year progression-free survival was 72.3 percent in the robotic arm and 71.6 percent in the open cystectomy arm (difference 0.7 percent, 95% CI -9.6 to 10.9 percent, p noninferiority = 0.001), thus indicating that robotic cystectomy was noninferior to open cystectomy for progression-free survival at two years .
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Laparoscopic and robotic surgery" and "Society guideline links: Bladder cancer" and "Society guideline links: Cystectomy".)
SUMMARY AND RECOMMENDATIONS
●Indications for radical cystectomy:
•Muscle-invasive bladder cancer (see 'Muscle-invasive bladder cancer' above):
-Treatment of choice for T2-T4a, M0 bladder cancer
-Salvage therapy for T4b or N1-3 bulky nodal diseases that respond to chemotherapy
•Non-muscle-invasive bladder cancer refractory to less invasive therapy (see 'Non-muscle-invasive bladder cancer' above):
-Diseases with very-high-risk features
-Persistent or recurrent disease
-Diffuse, Ta low-grade bladder cancer
-Intractable symptoms such as bleeding or urinary frequency
●Surgical steps for radical cystectomy (see 'Surgical steps' above):
•Cystectomy – Removal of the bladder (cystectomy) along with the organs at highest risk of harboring tumors that extend beyond the bladder and regional pelvic lymph nodes. (See 'Cystectomy' above.)
-In men, the prostate and seminal vesicles are also removed. In selected patients, nerve-sparing cystectomy may be performed to preserve potency if it does not compromise oncologic control. (See 'Men' above.)
-For women, some of the female reproductive organs (ie, uterus, cervix, ovaries, and vagina) may be removed to achieve complete resection, but pelvic-organ-preserving techniques should be applied when feasible. (See 'Women' above.)
•Lymphadenectomy – For patients undergoing radical cystectomy, we suggest an extended lymphadenectomy rather than a standard lymphadenectomy (Grade 2C). Extended lymphadenectomy includes dissection up to at least the aortic bifurcation and preferably up to the origin of the inferior mesenteric artery, especially when the cystectomy is for high-grade muscle-invasive disease. Standard lymphadenectomy, which requires removal of a minimum of 12 external iliac, internal iliac, or obturator nodes, may be a reasonable alternative in some patients. (See 'Lymphadenectomy' above.)
•Urinary diversion – Removal of the bladder requires that the urinary flow be redirected, which may result in either a noncontinent or continent diversion. (See "Urinary diversion and reconstruction following cystectomy".)
●Surgical approaches – Radical cystectomy can be performed open or with one of the minimally invasive approaches (laparoscopic or robotic). Our preference is to use the robotic technique, although the choice of approach should be based on patient and tumor factors as well as the surgeon's expertise and experience. (See 'Surgical approaches' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Andrew J Stephenson, MD, and Inderbir S Gill, MD, who contributed to earlier versions of this topic review.